HOME LANGUAGE SURVEY Student’s Name:

________________________________________

Student’s Grade:

Student’s School: _________________________________________ Today’s Date:

DATE: _____________________

___________________ ___________________

The U.S. Office of Civil Rights requires schools to identifying possible English Learners (ELs) during enrollment. This Home Language Survey (HLS) is used as a tool to determine if your child is eligible for language support services. If a language other than English is used by you or your child and your child meets the English Learner (EL) definition, the school may give your child an English Language Proficiency assessment. The school will share the results of the assessment with you. What language(s) are spoken at home?

________________________________________________

What language(s) do you use the most to speak to your child? What language(s) does your child use the most at home?

________________________________________________

________________________________________________

What language(s) did your child learn when he/she first began to talk? __________________________________________ List other language(s) that your child has used with a grandparent or caretaker: __________________________________ If available, in what language do you prefer to receive information from the school? _______________________________ Has your child ever been in an English as a Second Language (ESL or EL) Program?

Yes

No

Put an X in the boxes on the top line to show the school grade your child has attended in the United States. Put an X in the boxes on the bottom line to show the school grades your child attended in another country.

If your child has attended school outside of the United States: In which country or countries did your child attend school? ________________________________________________ Which language(s)did your child learn in school? ________________________________________________

This form also asks for information used by other programs to help your child in school. Answering questions 1-4, may qualify your child for additional services. Refugee Student: The NDDPI applies for a Refugee School Impact Grant to provide services for newly arrived refugee students. A refugee student left their home country due to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership in a particular social group, or political opinion and has fled to another country to be resettled. Newly arrived is defined as within the last three years. 1. Would your child be considered a newly arrived refugee student? Yes No Immigrant Student: Immigrant students are mentioned specifically in the EL definition and may qualify for EL services. Additionally, students who have attended schools in the U.S. for three years (3) or less may qualify for additional services. 2. Would your child be considered an immigrant student? Yes No If yes, please list the country ________________________ and U.S. entry date (mm/dd/yy) _____/_____/_____ (For refugee students, this is the country you originally fled, not the country you lived in most recently.) Native American or Alaska Native Student: Native American and Alaska Native students are mentioned specifically in the EL definition and may qualify for EL services. 3. Would your child be considered a Native American or an Alaska Native student? Yes No Migrant Student: Migrant students are mentioned specifically in the EL definition and may qualify for EL services. A migrant student has a parent who is a migratory agricultural worker and in the last three (3) years has moved from one school district to another, in order to work (temporary or seasonal) in agricultural activities. 4. Would your child be considered a migrant student? Yes No If yes, what is the date you moved to this area? (mm/dd/yy) _____/_____/_____ If your family moved to this area for agriculture (temporarily or seasonally), in what area(s) do you work: (please check all that apply) Potato Industry

Landscaping, Laying Sod or planting grass

Plant/Cultivate Trees

Turkey Farm/Processing

Egg ProductionMeat Processing Plant

Chicken Farms/Processing

Sugar Beet Industry

General Dairy Farm Work

Trimming Trees

Bee Keeper/Honey Processing

Transportation of Agricultural Products

Custom Combining

Raw Cheese Production Date student was tested for EL services:__________________________

Did the student qualify for EL services?

Yes

NO